health reimbursement arrangement plan design guide...health reimbursement arrangement (hra) plan...

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Health Reimbursement Arrangement (HRA) Plan Design Guide

Please complete this form and return to Further℠*, CareFirst’s HRA administrator, at least three weeks before your effective date to ensure proper administration of your plan. If you have any questions, please call BlueFund Customer Service at 866-758-6119. Send your completed form by secure email to [email protected] or mail it to Further, c/o CareFirst, P.O. Box 64193, St. Paul, MN 55164.

All fields are required unless otherwise noted. Incomplete forms will delay your plan setup.

1. EMPLOYER INFORMATION

Employer’s name

Employer’s tax ID number (required)

Type of corporation S Corporation C Corporation Partnership Sole Proprietor Political Subdivision/Church LLC Non-Profit Other

Number of employees eligible for the plan

Signing AuthorityThe person listed below is responsible for signing and approving the plan design guide and does not receive any marketing or operational communications from Further unless they are also the group administrator and the section below is left blank.

Name Title

Phone number Email address

Group Administrator (if different than above)The person listed below has access to all plan information when contacting Further and will automatically be granted full access to the online BlueFund account.

Main contact name Title


Additional Contact Person (optional)This person has access to the plan information indicated below when contacting Further. This person’s online access is granted by the group administrator within the CareFirst employer portal.

Additional contact name Title


This person has access to the following information when contacting Further:

All plan data Claim billing

To grant access to additional users or to add more contacts, log in to employer.carefirst.com. From the Finance tab, select BlueFund to access your account.

2. CAREFIRST INFORMATION

CareFirst account executive

Name

Phone number

Email address

CareFirst account manager

Name

Phone number

Email address

SUM4167-1E (10/19)

Further is an independent company that provides administrative services for CareFirst BlueCross BlueShield consumer-directed health care plans and incentive cards. Further does not sell BlueCross or BlueShield products.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

mailto:carefirstsales%40hellofurther.com?subject=

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3. AGENCY/BROKERAGE INFORMATION

Name of agency/brokerage (if applicable)

Agency/brokerage address

Agency/brokerage tax ID

Agent/broker’s name (if applicable) Email address

Agent/broker code (NPN) Agent/broker phone

4. TRANSFER OF ADMINISTRATION

Is Further replacing administrative services from another HRA administrator? Yes No

If yes, please complete the BlueFund HRA Transfer Addendum and submit with this plan design guide.

5. HEALTH PLAN ADMINISTRATIVE INFORMATION

Effective date

Are health plan accumulations per calendar year or plan year? Calendar year Plan year

Is your plan fully insured or self-insured? Fully insured Self-insured

6. ADMINISTRATIVE DEFINITIONS & NOTES

■ Medical crossover/autopay: CareFirst will send eligible claim expenses to Further electronically to be processed and reimbursed according to the employee’s available balance. Eligible expenses that would not be on a claims file (e.g., compliant over-the-counter medications), will require the employee to submit a request for reimbursement.

Please note: Autopay is not appropriate for individuals who have secondary health coverage. Those employees should be directed to turn off this feature in their spending account profile at carefirst.com/myaccount and submit manual reimbursement requests instead. Members with autopay do not receive debit cards.

■ Pay the provider: This feature allows an employee to have their medical claim reimbursement sent directly to their in-network provider, instead of to their home address or direct deposited into their bank account.

■ Providers are not paid at the time of service.

■ Network providers may request a copay or coinsurance amount from a member if they haven’t yet met their health plan deductible. Your employees would be responsible for working with their provider directly to be reimbursed once Further has sent payment to the provider. If a provider tries to collect a deposit amount that isn’t copay or coinsurance, this should be reported to CareFirst immediately.

■ Copays and prescription claim amounts are always paid to the employee and never to the provider, as it is assumed that the employee paid for this expense at the time of service.

■ Enrolled employees can choose to turn off the pay the provider option in their online profile.

Pay the provider is not available with the debit card option.For additional assistance in understanding your options with medical crossover/autopay and pay the provider, please see the HRA Employer Guide available on the BlueFund CDH resources page at employer.carefirst.com.

■ Locations: To request multiple Further locations, please complete and attach a Location Addendum. Locations must be the same across all products administered by Further. To request different ACH accounts by location, please complete the Group ACH Authorization Agreement Form.

■ Ineligible Employees: You may have shareholders or highly compensated employees who aren’t eligible to participate in an HRA. Please submit the HRA Ineligible Employee Form along with the plan design guide.

SUM4167-1E (10/19)

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7. HEALTH REIMBURSEMENT ARRANGEMENT (HRA) OPTIONS

How many different HRA plans will be offered to your employees? (select one) One Two Other

If you would like to select more than one HRA, be sure to complete Sections 7–10 for each HRA attached to a different health plan. Include the specific health plan name that is associated with each HRA plan design.

Plan YearIs the HRA funded per calendar year or plan year?

Calendar year start date: (calendar year end date is always the last day of the calendar year)

Plan year start date: End date:

Health Plan Name

Choose one of the two following HRA options:

OPTION #1—EMPLOYER PAYS FIRST HRA

With this option, you fund the HRA as expenses are reimbursed up to the preset amount you choose. The HRA pays until the funds are depleted. After that, the employee is responsible for out-of-pocket health care expenses.

Indicate the annual funding amount for the Employer Pays First HRA:

Member (single) = $ (required) Member + children = $

Member + child = $ Member + spouse + child(ren) (family) = $ (required)

Member + spouse = $

Eligible expenses, claims and reimbursement options—choose only ONE of the five following options:

1. All medical expenses (incl. deductible/copay/coinsurance) Debit card with employee option for medical crossover/autopay (default) Medical crossover/autopay only—select one of the following:

Enroll all employees in pay the provider automatically (Members can opt-out) Do not offer pay the provider

2. All health care eligible expenses (incl. medical/drug/dental/vision/otc) Debit card with employee option for medical crossover/autopay (default) Medical crossover/autopay only—select one of the following:


3. All medical and drug expenses Debit card with employee option for medical crossover/autopay (default) Medical crossover/autopay only—select one of the following:

Enroll all employees in pay the provider automatically. (Members can opt-out) Do not offer pay the provider

4. Medical deductible onlyMedical crossover/autopay only—select one of the following:

Enroll all employees in pay the provider automatically. (Members can opt-out) Do not offer pay the provider

5. Drug expenses onlyDebit card with employee option for medical crossover/autopay (default)

SUM4167-1E (10/19)

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7. HEALTH REIMBURSEMENT ARRANGEMENT (HRA) OPTIONS

OPTION #2—EMPLOYEE PAYS FIRST HRA

With this option, the employee pays out of pocket until the preset amount you choose below has been paid. When this amount has been reached, the HRA pays until depleted. You fund the HRA up to predetermined amount set by you. After that, the employee is responsible for out-of-pocket health care expenses.

Indicate your health plan deductible amounts by coverage tier:



Member + spouse = $

Indicate the employee responsibility amount*: (This is the amount that the employee will pay out of pocket prior to reimbursement from the employer funding amount.)



Member + spouse = $

Indicate the employer funding amount*: (This is the amount that the employer will pay for each coverage tier after the employee has satisfied their employee responsibility amount.)



Member + spouse = $

Eligible expenses, claims and reimbursement options—choose only ONE of the four following expense options:

1. All medical expenses (incl. deductible/copay/coinsurance) Medical crossover/autopay only


2. All health care eligible expenses (incl. medical/drug/dental/vision/otc)Medical crossover/autopay only


3. All medical and drug expensesMedical crossover/autopay only


4. Medical deductible onlyMedical crossover/autopay only


(continued)

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8. HEALTH REIMBURSEMENT ARRANGEMENT (HRA) ADMINISTRATIVE REQUIREMENTS

Mid-year enrollees/contract changes

Indicate how mid-year enrollees and contract changes will be administered: (select one)

HRA funding is 100% regardless of date of enrollment/contract change.

HRA funding is prorated in monthly increments back to the first of the month of the date of enrollment/contract change.

Rollover

Select one option below for unused balances at the end of the plan year. If an Employee Pays First HRA is selected, rollover dollars can only be used AFTER the annual employee responsibility amount has been met.

Entire balance rolls over to subsequent plan year

No balance rolls over

A dollar limit on the amount that can roll over to the subsequent plan year. Rollover amount cannot be the same as funding amount. Indicate limits below:



Member + spouse = $

Cap on HRA balance

Is there a cap on the overall balance (including rollover) that can accumulate in the account? Yes No

If yes, the recommended cap is the annual deductible amount or total annual out-of-pocket amount. Please indicate amounts below:



Member + spouse = $

Runout period

Members have months after the end of the plan year to submit claims incurred during that plan year. (The standard runout period is three months.)

The runout period noted above begins at termination date for terminated employees.

Terminations

Indicate what happens to the HRA balance when a member terminates and does not elect COBRA. NOTE: HRAs stay with terminated members if COBRA is elected (mandatory). Select one:

Account balance returns to employer if terminated member or eligible dependent does not elect COBRA. (Default)

Account balance remains with terminated member or eligible dependent to spend-down until funds are depleted. If spend-down is selected, eligible expenses for terminated members remain the same as for active members. Spend-down is subject to any applicable rollover and runout period provisions and fees. (Not available for Employee Pays First HRAs)

Copay amounts (not required if election is medical crossover/autopay only)

The copay amounts provided below will allow these amounts to auto-substantiate when the debit card is used. Documentation will not be required for reimbursements.

Please indicate the health plan copay amounts below or attach a separate spreadsheet indicating the copay amounts.

Medical Vision Drug

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9. CLAIM REIMBURSEMENT PROCESSING—Completion of this section is mandatory

You will receive an automated email notification with the claim reimbursement totals. Log in to employer.carefirst.com to view and print your complete invoice detail.

Automated Clearinghouse (ACH) information

I hereby authorize Further to charge our bank account through ACH for claim reimbursements. The following bank account information is provided to Further for initiation of this procedure.

Bank name

Bank ABA number Account type: Checking Savings (The ABA number is the nine-digit number located in the lower left corner of your check.)

Bank account number

10. SIGNATURE

I agree that necessary information concerning current and future members and/or their dependents who participate in this plan, and members whose participation is to be changed or discontinued, will be provided to Further on a timely basis.

I HAVE READ AND UNDERSTAND THE CHOICES WITHIN THIS PLAN DESIGN GUIDE. INFORMATION ON THE PLAN DESIGN GUIDE AND ANY ANCILLARY INFORMATION PROVIDED FOR THE PURPOSE OF ENROLLING IN THIS PLAN ARE, TO THE BEST OF MY KNOWLEDGE, CORRECT AND COMPLETE. Please note: A health savings account (HSA) plan paired with a health reimbursement arrangement (HRA) poses possible tax code concerns. An employee who enrolls in the HSA health plan and participates in the HRA may not be eligible to open or contribute to their own HSA. Employees must be advised.

This form requires an original signature or a certified electronic signature.

Signature Date

Printed name Title

11. FOR OFFICE USE ONLY

Further group number Sales executive

Market segment Further account manager

CareFirst account manager Further client manager

Broker partner Further enrollment specialist

Broker account manager

SUM4167-1E (10/19)

http://employer.carefirst.com

Notice of Nondiscrimination and Availability of Language Assistance Services(UPDATED 8/5/19)

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CareFirst:

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If you need these services, please call 855-258-6518.

If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.

To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office.

Civil Rights Coordinator, Corporate Office of Civil RightsMailing Address P.O. Box 8894 Baltimore, Maryland 21224

Email Address [email protected]

Telephone Number 410-528-7820 Fax Number 410-505-2011

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). The Blue Cross® and Blue Shield® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans.

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nɔ̀ɓà mɔ̀à 0 kɛɛ dyi pàɖàìn hwɛ̀. Ɔ jǔ ké nyɔ ɖò dyi m̀ gɔ ̃̌ jǔǐn, po wuɖu m̀ mɔ́ poɛ dyiɛ, ké nyɔ ɖò mu ɓó nììn

ɓɛ́ ɔ ké nì wuɖuɔ̀ mú zà.

বাাংলা (Bengali) লক্ষ্য করুন: এই ননাটিশে আপনার ববমা কভাশরজ সম্পশকে তথ্য রশেশে। এর মশযয গুরুত্বপূর্ে তাবরখ থ্াকশত পাশর এবাং বনবদেষ্ট তাবরশখর মশযয আপনাশক পদশক্ষ্প বনশত হশত পাশর। ববনা খরশে বনশজর ভাষাে এই তথ্য পাওোর এবাং সহােতা পাওোর অবযকার আপনার আশে। সদসযশদরশক তাশদর পবরেেপশের বপেশন থ্াকা নম্বশর কল করশত হশব। অশনযরা 855-258-6518 নম্বশর কল কশর 0 টিপশত না বলা পর্েন্ত অশপক্ষ্া করশত পাশরন। র্খন নকাশনা এশজন্ট উত্তর নদশবন তখন আপনার বনশজর ভাষার নাম বলনু এবাং আপনাশক নদাভাষীর সশে সাংর্ুক্ত করা হশব।

یہ نوٹس آپ کے انشورینس کوریج سے متعلق معلومات پر مشتمل ہے۔ اس میں کلیدی تاریخیں ہو سکتی ہیں اور ممکن :توجہ (Urduاردو )ہے کہ آپ کو مخصوص آخری تاریخوں تک کارروائی کرنے کی ضرورت پڑے۔ آپ کے پاس یہ معلومات حاصل کرنے اور بغیر خرچہ

کو اپنے شناختی کارڈ کی پشت پر موجود فون نمبر پر کال کرنی چاہیے۔ سبھی دیگر کیے اپنی زبان میں مدد حاصل کرنے کا حق ہے۔ ممبران

دبانے کو کہے جانے تک انتظار کریں۔ ایجنٹ کے جواب دینے پر اپنی مطلوبہ زبان 0پر کال کر سکتے ہیں اور 6518-258-855لوگ

بتائیں اور مترجم سے مربوط ہو جائیں گے۔

توجه: این اعالمیه حاوی اطالعاتی درباره پوشش بیمه شما است. ممکن است حاوی تاریخ های مھمی باشد و الزم است تا تاریخ (Farsiفارسی ). مقرر شده خاصی اقدام کنید. شما از این حق برخوردار هستید تا این اطالعات و راهنمایی را به صورت رایگان به زبان خودتان دریافت کنید

شان تماس بگیرند. سایر افراد می توانند با شماره ره درج شده در پشت کارت شناساییاعضا باید با شما

را فشار دهند. بعد از پاسخگویی توسط یکی از اپراتورها، زبان 0تماس بگیرند و منتظر بمانند تا از آنھا خواسته شود عدد 855-258-6518

.مورد نیاز را تنظیم کنید تا به مترجم مربوطه وصل شوید

اتخاذ إلى تحتاج وقد مھمة، تواریخ على یحتوي وقد التأمینیة، تغطیتك بشأن معلومات على اإلخطار هذا یحتوي :تنبیه (Arabic) العربیة اللغة االتصال األعضاء على ینبغي .تكلفة أي تحمل بدون بلغتك والمعلومات المساعدة هذه على الحصول لك یحق .محددة نھائیة مواعید بحلول إجراءات

الرقم على االتصال لآلخرین یمكن .بھم الخاصة الھویة تعریف بطاقة ظھر في المذكور الھاتف رقم على

بھا التواصل إلى تحتاج التي اللغة اذكر الوكالء، أحد إجابة عند .0 رقم على الضغط منھم یطلب حتى المحادثة خالل واالنتظار855-258-6518

.الفوریین المترجمین بأحد توصیلك وسیتم

中文繁体 (Traditional Chinese) 注意：本聲明包含關於您的保險給付相關資訊。本聲明可能包含重要日期及您在特定期限之前需要採取的行動。您有權利免費獲得這份資訊，以及透過您的母語提供的協助服

務。會員請撥打印在身分識別卡背面的電話號碼。其他所有人士可撥打電話 855-258-6518，並等候直到

對話提示按下按鍵 0。當接線生回答時，請說出您需要使用的語言，這樣您就能與口譯人員連線。

Igbo (Igbo) Nrụbama: Ọkwa a nwere ozi gbasara mkpuchi nchekwa onwe gị. Ọ nwere ike ịnwe ụbọchị ndị dị

mkpa, ị nwere ike ịme ihe tupu ụfọdụ ụbọchị njedebe. Ị nwere ikike ịnweta ozi na enyemaka a n’asụsụ gị na

akwụghị ụgwọ ọ bụla. Ndị otu kwesịrị ịkpọ akara ekwentị dị n’azụ nke kaadị njirimara ha. Ndị ọzọ niile nwere

ike ịkpọ 855-258-6518 wee chere ụbụbọ ahụ ruo mgbe amanyere ịpị 0. Mgbe onye nnọchite anya zara, kwuo

asụsụ ị chọrọ, a ga-ejikọ gị na onye ọkọwa okwu.

Deutsch (German) Achtung: Diese Mitteilung enthält Informationen über Ihren Versicherungsschutz. Sie kann

wichtige Termine beinhalten, und Sie müssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben

das Recht, diese Informationen und weitere Unterstützung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied

verwenden Sie bitte die auf der Rückseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen

bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu drücken. Geben Sie dem

Mitarbeiter die gewünschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.

Français (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates

importantes peuvent y figurer et il se peut que vous deviez entreprendre des démarches avant certaines échéances.

Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent

appeler le numéro de téléphone figurant à l'arrière de leur carte d'identification. Tous les autres peuvent appeler le

855-258-6518 et, après avoir écouté le message, appuyer sur le 0 lorsqu'ils seront invités à le faire. Lorsqu'un(e)

employé(e) répondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interprète.

한국어(Korean) 주의: 이 통지서에는 보험 커버리지에 대한 정보가 포함되어 있습니다. 주요 날짜 및 조치를 취해야 하는 특정 기한이 포함될 수 있습니다. 귀하에게는 사용 언어로 해당 정보와 지원을 받을

권리가 있습니다. 회원이신 경우 ID 카드의 뒷면에 있는 전화번호로 연락해 주십시오. 회원이 아니신 경우

855-258-6518 번으로 전화하여 0을 누르라는 메시지가 들릴 때까지 기다리십시오. 연결된 상담원에게

필요한 언어를 말씀하시면 통역 서비스에 연결해 드립니다.

(Navajo)

855-258-6518

Employers name 4: Employers Tax ID 4: Type of Corporation: OffType of Corp Other 2: Number of Employees Eligible 4: Name 3: Title 3: Phone number 3: Fax number 3: Name 7: Title 4: Phone number 4: Fax number 4: Name 6: Title 5: Phone number 5: Fax number 5: Access: OffName 4: Phone 4: Email 4: Name 9: Phone 7: Email 7: Accumulations: OffName of agency-brokerage: Agency-brokerage address: Agency-brokerage tax id: Name of agent-broker: Agent-broker email: Agent-broker code: Further administration: OffHealth plan effective date 2: Insured: OffHRA funding: OffFunding option: OffOption 1: 1: Off

Calendar start date: Plan year start date: Plan year end date: Opt 1 Member 2: Opt 1 Member-Children 3: Opt 1 Member-Child 2: Opt 1 Member-Spouse-Children 3: Opt 1 Member-Spouse 2: Opt 1 Member 3: Opt 1 Member-Children 4: Opt 1 Member-Child 3: Opt 1 Member-Spouse-Children 4: Opt 1 Member-Spouse 3: Opt 1 Member 4: Opt 1 Member-Children 5: Opt 1 Member-Child 4: Opt 1 Member-Spouse-Children 5: Opt 1 Member-Spouse 4: Opt 1 Member 5: Opt 1 Member-Children 6: Opt 1 Member-Child 5: Opt 1 Member-Spouse-Children 6: Opt 1 Member-Spouse 5: Midyear funding: OffRollover: OffTerminations: OffOpt 1 Member 6: Opt 1 Member-Children 7: Opt 1 Member-Child 6: Opt 1 Member-Spouse-Children 7: Opt 1 Member-Spouse 6: Cap on HRA balance: OffOpt 1 Member 7: Opt 1 Member-Children 8: Opt 1 Member-Child 7: Opt 1 Member-Spouse-Children 8: Opt 1 Member-Spouse 7: Runout period months: Medical copay 2: Vision copay 2: Drug copay 2: ACH Account type: OffACH Bank name 3: ACH Bank number 3: ACH Bank account number 3: Date: Signature printed: Signature title: Further group number: Sales executive: Market segment: Further account manager: CareFirst account manager: Client manager: Broker partner: Enrollment specialist: Broker account manager:

health reimbursement arrangement plan design guide...health reimbursement arrangement (hra) plan...

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